Quality of life of older adults in Family Health Strategy: a cross-sectional study

ABSTRACT BACKGROUND: With the increase in the older adult population, it is essential to identify the living and health conditions that can impact the quality of life of these individuals. OBJECTIVES: To identify the domains and factors associated with the quality of life of older adults under the Family Health Strategy program. DESIGN AND SETTING: This was a cross-sectional analytical study was conducted in the municipality of Palmas, Tocantins, Brazil. METHODS: We assessed 449 older adults enrolled in the Family Health Strategy program. Data were collected between April and July, 2018. World Health Organization Quality of Life Assessment (WHOQOL-OLD) was used to assess the quality of life (QoL) and multiple linear regression was used to estimate the factors associated with QoL. RESULTS: The QoL domain with the highest score was death and dying (mean = 70.4), and the lowest score was for sensory functions (mean = 61.0 points). The factors associated with QoL were single marital status (β = -4.55; P = 0.014), level of independence for daily living activities (β = 4.92; P < 0.001), self-assessment of regular health (β = 5.35; P < 0.001), and poor health (β = -8.67; P < 0.001). CONCLUSION: The death and dying domain of QoL presented the highest score. Marital status, impairment in daily activities, and health self-assessment were associated with QoL.


INTRODUCTION
Creating opportunities for healthy aging is becoming increasingly important as the global population continues to grow. 1 Functional ability is a critical component of healthy aging, as it allows individuals to maintain their independence and quality of life as they age. Intrinsic capacity, which includes both physical and mental capacity, is an essential part of functional ability.
Concordance between these attributes is a key determinant for the maintenance of quality of life and the factors that most negatively or positively influence this construct. 1,2 Quality of life (QoL) is defined as "the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns". 3 In this way, QoL in old age is related to health as well as to physical, functional, cognitive, and emotional well-being, and other areas such as work, family, and daily living. 4 The literature highlights conditions that are associated with good QoL among older people, including physical exercise, age, access to medical care, absence of depression, and fewer diseases. 5,6 Factors that stood out in association with a worse QoL were cognitive decline and impairment of functional capacity and autonomy. 7,8 In this context, primary healthcare is older adults' access to health services through the Family Health Strategy (FHS) program, which continuously monitors users. Thus, it is important that the FHS multiprofessional and/or interdisciplinary team take a continuous and comprehensive look at the health of older adults and its impact on QoL.
Considering the increase in the older population, it is essential to identify the living and health conditions that can affect the QoL of older adults. These findings can assist FHS teams in carrying out actions to promote health and prevent health problems, as well as carry out interventions aimed at improving the QoL of the older population.  Health conditions included health self-assessment report (very good/good, regular, poor/very poor), multimorbidity (≥ 2 chronic diseases), polypharmacy (≥ 5 regular use of medications), cognition, performance in basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), and history of hospitalization in the year prior to the interview.

Cognitive impairment was screened using the Mini-Mental
State Examination (MMSE) 11,12 with scores ranging from 0 to 30.
A score of less than 20 was considered as cognitive impairment for individuals with no schooling, and less than 24 for individuals with schooling. 13 The Katz Index was used to assess ADL (bathing, dressing, toileting, transferring, continence, and feeding) 14 and older people who reported dependence on one or more activities were classified as dependent. IADL was measured using the Lawton-Brody Scale, which assesses a person's ability to perform tasks such as using a telephone, shopping, preparing food, housekeeping, doing laundry, using transportation, handling medications, and handling finances. 15 Older adults who scored between 26 and 27 were considered independent, and those who scored ≤ 25 points showed mild dependence.

Data analysis
Data were entered into Microsoft Excel and analyzed using

DISCUSSION
In the present study, the facet of QoL with the highest mean score was death and dying (mean = 70.4), indicating that the perception of death had no negative influence on participants' QoL. This result is in agreement with other studies carried out with Brazilian older adults. [16][17][18] According to Ermel et al., 16 older Brazilian individuals have a greater fear of feeling pain before dying than the fear of death itself. This finding may also be associated with psychological resilience among older adults.
Psychological resilience can be viewed as the set of personal resources that individuals acquire throughout their life and which help them to positively adapt to risks, threats, and losses over time. 19 In other words, older people can be less concerned about death precisely because they are more resilient in the face of adversity, as they have experienced multiple losses of partners or spouses, family members, friends, and social roles, as well as declining health. 20 In contrast to death and dying, the sensory functioning facet presented the lowest score for QoL in this study (mean = 61.0), followed by facet autonomy (mean = 62.7). This finding is in line with several studies since sensory loss becomes more common with aging, negatively impacting the QoL, functional capacity, and autonomy of older adults. 21,22 A systematic review 22 on sensory ability evaluated 23 studies to determine the relationship between QoL and hearing loss/impairment and found that limitations in activities of daily living and a decrease in social and emotional resources were the main causes of a lower QoL. These limitations affect the intrinsic capacity of an individual because they are associated with all the activities that older adults perform over time. In addition, their ability to communicate and socialize might be reduced, thereby worsening their isolation. The association between these factors predisposes individuals to a greater propensity to depression, sadness, and anger, resulting in a low QoL and the impairment of healthy aging. 1,22 With increasing age, certain sensory losses affect the way older individuals experience the world and react to it, which may lead to difficulty in performing basic and instrumental activities of daily living, and a consequent increase in dependence. Attention is drawn to these changes as they can be detected early in FHS, contributing to extending the QoL and functionality of older adults.
In the population studied, the factors associated with QoL that stood out were being single, a health self-assessment of poor, and independence in instrumental activities of daily living.
Marital status is an important health determinant, and with advancing age, being married is a protective factor against depression and anxiety, and improves the QoL. Most married individuals, when compared to those who did not have a partner, presented a better assessment of QoL than single and widowed older adults. 23,24 The results of this study indicate that social and affective ties become more important with age. The lack of a social support network or inappropriate support is a predictor of mortality and is associated with higher rates of depression, disability, loneliness, and poor QoL in older people. 25 However, a review showed that widowed and divorced individuals are more exposed to a greater risk of lack of support when compared to single individuals, because the latter tend to form more friendship ties over the years, which can act as a support network. 25 In relation to health self-assessment, a worsening in QoL was found among those self-rated as regular (β = -5.35) and as poor/ very poor (β = -8.67). Health self-assessment reflects the knowledge and beliefs that individuals have about their health, considering  physical, cognitive, and emotional indicators, and is a good predictor of morbidity, mortality, and functionality among older adults. 26 A study on the health self-assessment of older participants showed a higher prevalence of self-ratings of poor/very poor and its association with aspects of physical and mental health, sense of happiness, and socioeconomic status. 27 Other authors reported that sociodemographic factors, health status, and functional impairment led to negative self-ratings among older people. 28 In this study sample, the facet of independence in IADLs showed an average increase of 4.92 units in the QoL score (β = 4.92) compared with individuals dependent on assistance to perform certain instrumental tasks. This result corroborates data from another study conducted in the state of São Paulo, in which older adults with worse QoL scores were 3.5 times more likely to have functional disability in IADL. 29 Although the present study could not establish an association between QoL and sex or age, the literature indicates that women have worse mean disability scores than men, which was not found in the multiple analyses. Part of this difference may be due to the male-female health-survival paradox, which considers behavioral aspects and exposure throughout life. 30 Men are affected by diseases that lead to death more quickly, while women live longer than men; however, they suffer more chronic diseases that lead to disabilities and tend to live longer with disabilities. Thus, although women live longer, this does not necessarily mean that they do so with a high QoL. [30][31][32] Other explanations for the comparatively worse QoL of women are based on cultural and gender aspects. As women work a triple shift (care, family responsibilities, and career responsibilities), they tend to experience greater mental overload. 33 Nevertheless, this study found that age had no significant association with QoL, corroborating with the results of a study conducted with Portuguese and Spanish older adults that showed no statistical difference between the groups, indicating that age did not have a great influence on QoL. 34 On the other hand, Nguyen et al. reported that increasing age influenced the scores of QoL.
Both men and women aged 80 years and over were more likely to have a lower QoL than younger older adults. 33 The main limitation of this study is its cross-sectional design, which does not allow the establishment of a cause-and-effect relationship between the variables. Furthermore, individuals who were completely dependent were not included in the sample, and the results could not be extrapolated to the older population. The strengths of our study lie in the representative sampling, which contributes to the external validity of the results. Additionally, it focuses on the QoL of participants from a region that has rarely been studied in the literature, allowing us to infer comparisons of the demands and specificities of the older population in each region.

CONCLUSIONS
The results showed that the factors associated with the worsening of QoL of older adults were being single and health self-assessment of regular or poor/very poor, while the best QoL was perceived among older individuals who were independent in performing instrumental activities of daily living. The mean QoL score of the surveyed group was the highest for the death and dying facet, demonstrating the best score for QoL. In contrast, the sensory functioning facet had the lowest mean and worst perception among older adults. The information provided by this study can assist in devising strategies to help older adults maintain a good quality of life as well as guide primary care health professionals in meeting the demands and needs of this population, applying care plans, and developing health actions to aid healthy and active aging.